Internet-based peer support interventions for people living with HIV: A scoping review

Peer support interventions for people living with HIV and AIDS (PLWHA) are effective, but their associated time and material costs for the recipient and the health system make them reachable for only a small proportion of PLWHA. Internet-based interventions are an effective alternative for delivering psychosocial interventions for PLWHA as they are more accessible. Currently, no reviews are focusing on internet-based interventions with peer support components. This scoping review aims to map the existing literature on psychosocial interventions for PLWHA based on peer support and delivered through the internet. We conducted a systematic scoping review of academic literature following methodological guidelines for scoping reviews, and 28 articles met our criteria. We summarized the main characteristics of the digital peer support interventions for PLWHA and how they implemented peer support in a virtual environment. Overall the reported outcomes appeared promising, but more robust evidence is needed.


Introduction
Human Immunodeficiency Virus (HIV) affects more than 37.7 million people worldwide and its prevalence is still increasing [1]. The primary HIV treatment is Antiretroviral Therapy (ART) which works to suppress replication of the virus resulting in improved immune response and reduced viral load. However, inadequate adherence to ART is associated with morbidity and mortality [2][3][4].
Peer support interventions are recommended in official health guidelines such as the Center for Disease and Prevention [49] and the British HIV Association [50].
However, these services are rarely offered in HIV clinics due to existing structural barriers, such as a lack of mental health services and difficulties in accessing services [51,52]. Against this scenario, internet-based interventions have proliferated. These are easy to access by many people due to resource-saving and flexible delivery [53]. Additionally, internet-based interventions offer anonymity, are easily accessible, and are also scalable [51, 54-56]. Therefore, they have been suggested as an alternative to overcome the barriers mentioned above [57,58].
Recent reviews of internet-based interventions have significantly impacted outcomes, including adherence, viral load, mental health, and social support for PLWHA [59,60].
However, none of the reviews has focused on peer support interventions delivered virtually.
We conducted a scoping review to map the existing literature on psychosocial interventions for PLWHA based on peer support and delivered through the internet. We chose the scoping review methodology developed by Peters and colleagues [61] since it allows comprehensive identification of the types and nature of psychosocial interventions for PLWHA, based on peer support and delivered through the internet described in the published literature [61]. Specifically, this review aims to answer the following questions: 1) What internet-based peer support interventions are available for PLWHA? What are their main characteristics? 2) How do the available interventions integrate peer support?
To our knowledge, this is the first systematic effort to provide such an overview.

Protocol and registration
We conducted a systematic scoping review of the peer-reviewed academic literature following the Joanna Briggs Institute (JBI) methodological guidance for scoping review [62] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews [63] Our pre-registered protocol containing the detailed methods is available at Open Science Framework (http://osf.io/r729p) (S1 Appendix).

Eligibility criteria
We included studies about psychosocial interventions designed explicitly for PLWHA and AIDS, based on peer support and delivered through technological devices and/or the internet. For this scoping review, any comparator was relevant for inclusion, and studies without a comparator were also assessed for eligibility. All available publications were eligible for inclusion (e.g., articles -any design, excluding systematic and scoping reviews-articles in conference proceedings, websites, chapters in textbooks). This scoping review had no limitations regarding the time of publication and duration of the intervention and no language restriction. S1 and S2 Appendices show the eligibility criteria and the search strategy.

Search
We developed the search strategy using the PRESS (Peer Review of Electronic Search Strategies) checklist [74], which was adapted to three databases. This step was conducted by the investigators (S.C.C. & A.G.C.) without the collaboration of a librarian due to institutional limitations. The words used were related to telemedicine or internet-delivered interventions (i.e., ehealth, digital health, mobile health), HIV or AIDS, and peer support or support group (for the complete search string, see S3 Appendix) were searched in the articles' title. No other limitation was applied to the search.

Sources of evidence selection
The database and manual searches were exported into Microsoft Excel [75]. Duplicate papers were removed. Two reviewers (S.C.C. & A.G.C.) independently screened each article for inclusion by title, excluding articles that failed the eligibility criteria. Then, the same two reviewers independently screened the article by abstract using a Google form questionnaire containing details to inform decision-making about inclusion/exclusion. Disagreements between reviewers were resolved through an iterative consensus process involving multiple rounds of deliberative discussion.

Data charting process
The authors developed a Google form questionnaire with detailed instructions (S.C.C. & A.G. C.) and were approved by the research team to achieve the charting process. This form was guided by the objectives of the present review, being the items related to articles' characterization and their conceptualization of peer support. To ensure internal consistency, some articles were codified in duplicate by two authors (S.C.C. & A.G.C.) and the rest was done independently by the same researchers.

Data items
First, articles' data were sought regarding study characterization: 1) year of publication; 2) location of the study; 3) study design/article type; 4) population; 5) name of the intervention; and 6) type of technology used. Then, the articles were revised to identify their conceptualization of the peer support component of the intervention (i.e., peer support application).

Selection of sources of evidence
The initial search yielded 517 articles, and 15 more were found by manual search from reviews' citations. After the removal of duplicate titles, 416 articles were left. Then, two authors (S.C.C. & A.G.C.) screened titles and abstracts, and 28 articles were included in the review and went through the codification process (Fig 1).

Synthesis of results
Peer support interventions. Table 2 summarizes the total of interventions included and reviewed in this work. Only 20 of the total of 28 mentioned a specific name for the intervention.
Interventions' main characteristics. The total of interventions included were codified according to their characteristics such as target population, eHealth type and the objective of each intervention. Table 3 summarizes the information of these categories.
Type of digital health. The interventions used a myriad of digital tools to be delivered. The use of social networking platforms such as Facebook and WhatsApp was one of the most frequent strategies (n = 7) of the reviewed studies [79,83,85,92,93,100,101], as well as the use Randomized Clinical Trial 2 (7.14) Randomized Clinical Trial 1 (3. 57) of websites (n = 7) [80-82, 86, 98, 102, 103]. The development of a smartphone App was also present in 4 interventions [77,88,96,99], along with the use of SMS and phone calls to establish communication between peers [78,81,85,93]. Only three studies developed a web-based platform [84,94,95], two used SMS communication exclusively [87,97], and two interventions were delivered via videoconference [90,98]. Only one intervention showed the partici-pants´videos made by peers [104].
Peer support implementation. The role of peer support was incorporated differently in the revised interventions. Some interventions combined more than one strategy to implement peer support. The communication via posts in a group board or online forums was one of the most common interventions (n = 7) [79-82, 94, 99, 103], followed by the use of peer counselors (n = 5) [78,81,84,87,98] and the use of SMS or WhatsApp to establish contact between peers (n = 5) [81,88,[91][92][93]. Implementing trained peers to provide psychosocial and logistical support was also a strategy for four of the revised interventions [77,85,86,102], and the use of online support groups was also frequently presented in the interventions [83,90,100,101]. Two of the reviewed studies used online focus groups [96,97], one implemented peer education [89], and only one used videos made by peers [104]. At last, one intervention generated a strategy of matched peers who had similar trauma experiences [95]. As an important component, three of the reviewed interventions incorporated peer support anonymously [79,96,99]. Table 4 summarizes the type of peer support implemented by each intervention.

Summary
This review aimed to systematically scope the empirical literature on peer-support psychosocial interventions for PLWHA. More specifically, we aimed to 1) identify the existent digital peer support interventions currently available for PLWHA; 2) summarize the main characteristics of the available interventions 3) examine how the interventions implemented peer support in a virtual environment. Twenty-eight studies were identified in a systematic search across peer-reviewed journals. Papers were primarily pilot studies and protocols published in North America or Africa within the last 5 years. This recent increase in papers reflects the growing interest in developing peer-support eHealth interventions for PLWHA. Even though only three studies were RCT, the relatively large number of RCT protocols suggests that this field will continue growing in the coming years. Participants were mainly HIV+ adults predominantly from minority ethnic, racial and/or sexual backgrounds. None of the studies was conducted in Latin America, which is problematic considering the high prevalence of HIV (approximately 1.8 million people in 2017) [105,106], the difficulties presented in achieving the 90-90-90 targets designated by UNAIDS [107], and the tendency for late treatment initiation [105].
Social networks and messaging apps (such as Facebook or WhatsApp) were the most frequently used digital health tools, which is consistent with research suggesting the increasing validity of psychosocial interventions using social networks for different populations [108][109][110]. Considering the ongoing massification of both smartphones [111][112][113] and access to the internet worldwide [114,115], this is a positive finding and suggests that there are indeed eHealth interventions that could be more widely accessed. The most common peer activity was the participation in social networking posting, peer counseling, and peer discussions and conversations through WhatsApp or other social messaging services, which are considered to be an asynchronous form of technology [116].
Interestingly, very few interventions [78,[96][97][98] incorporating face-to-face synchronic interaction were identified. Even though numerous studies have shown that synchronous technologies (such as real-time video conferencing) are a valid method to deliver group psychosocial interventions [116,117], real-time activities present constraints (i.e., scheduling) that can be overcome with asynchronous technologies [116].
Also, digital support emerges as a promising approach to complement healthcare [118,119]. For instance, through digital peer support, patients may have more efficient access to both health care services and HIV-related information (e.g., whether and how often the person should seek medical assistance based on symptoms).

PLOS ONE
It is worth noting that although internet-based interventions may help ease difficulties in access for some PLWHA-access to these interventions may be limited for some populations and marginalized groups (e.,g., older people, people with severe mental health conditions, people with specific disabilities,) [120][121][122]. Likewise, the risk of digital exclusion may make a strong point for face to face services.

Limitations
Our scoping review has two main limitations. Firstly, it was conducted only in 3 databases (PUBMED, Web of Science, and CINAHL Complete). The selection of these databases was due to a limited institutional budget; for this reason, some databases were excluded (e.g., EMBASE, Cochrane).
Secondly, and also due to institutional limitations, we did not count with the collaboration of a librarian, which may have had an impact on the expertise in designing and refining the main gsearch of our paper.

Conclusion
In this review we have summarized the digital peer support interventions currently available for PLWHA, their main characteristics, and the way in which they implemented peer support in a virtual environment.
Overall the reported outcomes appeared promising, especially regarding potential improvements in treatment adherence and enhanced perceived social support. Future research should focus on continuing collecting data through RCTs studies in diverse social contexts. Having robust diverse evidence of the effectiveness of this type of interventions may help expand the scope and the impact of different treatments.